NURS 6512 WK4 CASESTUDY
Differential Diagnosis for Skin Condition
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NURS 6512 WK4 CASESTUDY
Differential Diagnosis for Skin Condition
Comprehensive SOAP Template
Patient Initials: OC Age: 41 Gender: M
Note: The mnemonic below is included for your reference and should be removed before the submission of your final note.
L =location O= onset
C= character
A= associated signs and symptoms T= timing
E= exacerbating/relieving factors S= severity
SUBJECTIVE DATA: “I have a sort of dry rash, that’s peeling and itching and is getting
worst.”
Chief Complaint (CC): Skin condition #5. Skin abnormality noticed approximately 3 weeks ago and has gotten progressively worst in dryness and some bleeding to the site. The site is primarily the neck and chest region.
History of Present Illness (HPI): OC is a 41-year-old male who presents to the clinic with patchy, flaky, and scaly skin on the neck and chest regions. The patient states that the onset of this condition was approximately 2-3 weeks ago and has gotten progressively worst. The patient states that he has not made any major changes to his skin care products to warrant this
dryness. Itching is reported and has gotten progressively worst. The patient’s occupation as an accountant has recently triggered some stressful situations with recent layoffs, which he attributes might be a contributing factor to his condition. There is no pain associated, however, discomfort is reported. He has tried Aveeno cream and states this provides some temporary relief to the dryness and itching.
Medications: 1) Pantoprazole 40 mg PO Daily
2) Aspirin 81 mg PO Daily
Allergies: Penicillin (Anaphylaxis as a child)
Past Medical History (PMH): Esophagitis, Right Bundle Branch Block
Past Surgical History (PSH): Tonsillectomy
Sexual/Reproductive History: N/A
Personal/Social History: Drinks socially, denies tobacco use, no risky sexual behavior has one partner as the patient is married.
Immunization History: Immunizations are up to date. Last Tdap Fall 2015, Flu 2017, pneumonia 2011
Significant Family History: Father: Cirrhosis of liver, Alcoholism, DM type 2.
Mother: HTN. Reports no siblings or children
Lifestyle: Patient is a Hispanic male who is an accountant for a manufacturing plant who has been experiencing a significant amount of layoffs recently. He states this his living situation is very stable with minimal debt, however, the wife is currently unemployed and looking for employment.
Review of Systems:
General: Denies any recent weight changes, weakness, fatigue, or fever
Diet: Denies changes in appetite, restrictions, or taking vitamins and supplements
HEENT: Patient does not use glasses. Denies vision changes, discharge from eyes, hearing loss, tinnitus, or discharge from ears. Denies nasal congestion, drainage, or loss/decrease in sense of smell. Denies any concerns with teeth, mouth, tongue, or swallowing concerns.
Neck: Red patches of skin covered with thick, silvery scales.
Respiratory: Denies difficulty breathing. Denies hemoptysis, sputum production, cough, or dyspnea on exertion. Denies exposure to TB.
Cardiovascular/Peripheral Vascular: Denies chest pain, palpitations, edema, recent weight gains, orthopnea, has a history of right bundle branch block. Previous stress test conducted by a cardiologist was negative.
Gastrointestinal: reports indigestion and occasional acid reflux, currently on pantoprazole daily. Denies constipation or diarrhea. Reports regular bowel pattern.
Genitourinary: Denies changes in bladder pattern, dysuria, incontinence, urgency, or difficulty starting or maintaining stream. Reports regular self-testicular exams. Drinks approximately 4 liters of water per day.
Musculoskeletal: Denies bone/joint pain. Reports full ROM. Denies heat swelling
Psychiatric: reports anxiety, high stress, and insomnia. Denies thoughts of suicide or harm to others. No delusions of disordered thinking. Denies diagnosed mental health disorder, however, is constantly anxious.
Neurological: Denies dizziness, vertigo, loss of sensation, difficulty with memory, or seizure activity.
Skin: reports white patchy and scaly lesions on neck and top half of torso region. Three to four papules are also reported in his back region. Denies other bodily lesions, bruising, cuts, abrasions. No skin cancer history. Reports occasional itching to neck, chest, and back regions.
Hematologic: Denies hx of bleeding and excessive bruising. Denies previous blood transfusions.
Endocrine: Denies heat/cold intolerance, weight changes, polydipsia, polyuria, hair changes, increased hat, glove, or shoe size.
Allergic/Immunologic: reports seasonal allergies. Denies other immune deficiencies.
OBJECTIVE DATA:
Physical Exam:
Vital signs: B/P 114/71, left arm and sitting; P 70; T 98.0 orally; RR 12; non-labored; Wt: 207 lbs; Ht: 5’10”; BMI 24.5.
General: AAO X 4 strong motor activity and gait no supportive devices used.
HEENT:
Neck:
Chest Lungs:
Heart
Peripheral Vascular: Abdomen: Genital/Rectal: Musculoskeletal:
Neurological: Skin:
Include any labs, x-rays, or other diagnostics that are needed to develop the differential diagnoses.
ASSESSMENT:
Psoriasis: Is characterized by dry, raised, red skin lesions covered with silvery scales (Goljan, 2014). These lesions may be itchy or painful and there may be few or many. Also defined as unregulated proliferation (hyperplasia) of keratinocytes (McCance , Huether, Brashers, & Rote, 2014).
Eczema: also known as inflammatory dermatoses. Principal characteristic is pruritus (McCance et al., 2014). Acute eczema presents as weeping, erythematous rash with vesicles. Chronic eczema presents as dry, thickened skin caused by continual
scratching (Hammer & McPhee, 2014).
Systemic lupus erythematosus (SLE): is manifested by genetic, immunologic, and environmental factors that damage cells and leads to a formation of autoantibodies against double-stranded DNA (McCance et al., 2014). SLE primarily involves skin, joints, serosal membranes, blood cells, nervous system, and kidneys (Hammer & McPhee, 2014). Most common in women of childbearing age. Most common in Blacks, Asians, and Hispanics than Caucasians.
Diagnosis:
PSORIASIS
PLAN: This section is not required for the assignments in this course (NURS 6512) but will be required for future courses.
REFLECTION:This section is not required for the assignments in this course (NURS 6512) but will be required for future courses. Reflect on your clinical experience, and consider the following questions: What did you learn from this experience? What would you do differently? Do you agree with your preceptor based on the evidence?
References
Goljan, E. F. (2014). Rapid review: Pathology (4th ed.). Philadelphia, PA: Elsevier.
Hammer, G. D., & McPhee, S. J. (2014). Pathophysiology of disease: An introduction to clinical medicine (7th ed.). China: McGraw Hill.
McCance , K. L., Huether, S. E., Brashers, V. L., & Rote, N. S. (2014). Pathophysiology: The biologic basis for disease in adults and children (7th ed.). St. Louis, MS: Elsevier. [Show Less]